CUES OBJECTIVE: inability to put clothing on upper/lowe r body inability to maintain appearance at a satisfactory level

NURSING DIAGNOSIS Self-care deficit related to weakness as manifested by grooming deficit

ANALYSIS Due to the patient's condition, there is an inability to perform or complete dressing and grooming, complete feeding, bathing/hygie ne, or toileting activities for oneself

OBJECTIVE

NURSING ACTION

NURSING ORDER

RATIONALE

EVALUATION Goal partially met. After 1-2 hours of nursing intervention, the patient was able to identify individual areas of weakness/needs

After 1-2 To hours of identify nursing causative/ intervention, contributi the patient ng factors will be able to identify individual areas of weakness/nee ds

Determin Affecting e ability of age/developm individual to ental issues participate in own care note noncontamina nt medical problems/exis ting conditions that may be factors for care Enhances commitment to promote plan, client's optimizing participation outcomes, and in problem supporting identification recovery and/or and desired health goals and promotion. decision making. To discover barriers to Plan time participation in for listening regimen and to to client's work on feelings/conc problem erns. solutions.

 to assist in correcting /dealing with situation:

Provide communi cation among those who are involved in caring fro/assisti ng the client. Allow sufficient time for client to accompli sh tasks.

Enhanhces the coordination and continuity of care.

CUES

NURSING DIAGNOSIS Decreased cardiac output related to altered heart rate/ rhythm as manifested by EKG (ECG) changes

ANALYSIS

OBJECTIVE

NURSING ACTION

NURSING ORDER Keep client on bed or chair rest on position of comfort. Monitor vital signs frequently.

RATIONALE

EVALUATION

OBJECTIVE: altered heart rate or rhythm.

Due to the patient's condition, there is an inadequate blood pumped by the heart to meet the metabolic demands of the body.

After 8 hour To of nursing minimize/c intervention orrect the patient causative will be able to factors, participate in maximize activities that cardiac reduce the output workload of the heart.

De creases oxygen consumption and risk of decompensat ion.

Goal partially met.

Schedule activities and assessments Provide psychosocial support.

After 8 hour of nursing intervention the patient was able to participate in Pro activities that reduce the vides baseline for workload of the comparison heart. to follow trends and evaluate response to interventions . To maximize sleep periods. Ho nesty can be reassuring when so much

 Encourage relaxation techniques

activity and worry are apparent to the client. To reduce anxiety.